Technique: laparoscopic segmental gastrectomy

The description of the technique of laparoscopic segmental gastrectomy covers all aspects of the surgical procedure used for the management of benign gastric tumors. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: tumors/anterior aspect, tumors/posterior aspect, tumors/hard to identify, complications, intraoperative complications, postoperative complications, functional complications. Consequently, this operating technique is well standardized for the management of this condition.

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Technique:   laparoscopic   segmental   gastrectomy

Authors
D Mutter
Abstract
The description of the technique of laparoscopic segmental gastrectomy covers all aspects of the surgical procedure used for the management of benign gastric tumors.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: tumors/anterior aspect, tumors/posterior aspect, tumors/hard to identify, complications, intraoperative complications, postoperative complications, functional complications.
Consequently, this operating technique is well standardized for the management of this condition.
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2001-07
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E-publication
WeBSurg.com, Jul 2001;1(07).
URL: http://www.websurg.com/doi-ot02en169.htm

Technique:   laparoscopic   segmental   gastrectomy

1. Introduction
Benign gastric tumors are detected with increasing frequency, due to the combination of improved imaging modalities (ultrasonography, CT scanning, and MRI) and aggressive use of endoscopy.

Surgical resection of benign gastric tumors can be indicated to establish a histological diagnosis, to avoid the potential risk of malignant degeneration or the need for continued surveillance, and to alleviate concerns on the part of the patient and physician. Such resections are termed modified gastric resections as they are generally performed along non-anatomical lines, and have been made more appealing by the application of minimally invasive techniques.
2. General anatomy
• Anatomical description
• Landmarks
The stomach is a J-shaped mobile sac located between 2 fixed anatomical landmarks:
1. The cardia, junction between the abdominal esophagus and the stomach,
2. The pylorus, junction between the stomach and the duodenum.
• Division
The stomach is divided into 2 parts:
3. The vertical part projects over the spine to the left; it is composed of both the fundus and the body of the stomach,
4. The horizontal part heads to the right beyond the linea alba, composed primarily of the antrum of the stomach.
• Duodenal bulb
5. The duodenal bulb, often resected during gastrectomies due to its proximity to the stomach, is the first mobile segment of duodenum. It is separated from the pancreas by the omental bursa, which extends to the level of the gastroduodenal artery.
• Physiological description
From a physiological standpoint, the stomach divided into the:
6. Antrum: acid-stimulating,
7. Fundus: acid-producing.
The limit between the 2 functional regions does not correspond to the junction between the horizontal and vertical regions of the stomach.
3. Vascular anatomy
• Pedicles
Gastric arterial blood supply originates from the celiac trunk and supplies the stomach via 4 major pedicles:
- 2 at the level of the lesser curvature,
- 2 at the level of the greater curvature.
The stomach is endowed with a rich submucosal anastomotic network that ensures adequate blood supply in the event one of the main trunks is either obstructed or ligated.
• Celiac trunk
The celiac trunk, representing the main blood supply of the stomach, originates from the anterior aspect of the aorta above the superior aspect of the pancreas.
The trunk is 1 to 3 cm long and divides into 3 branches:
1. The left gastric artery;
2. The common hepatic artery;
3. The splenic artery.
• Gastroduodenal junction
The first portion of the duodenum is supplied by branches of the gastroduodenal artery.
4. Lesser curvature
• Left gastric artery
• Origin
The left gastric artery originates from the celiac trunk in 90% of cases.
• Variations
In some patients, it may originate:
1. Directly from the aorta;
2. From the inferior phrenic artery;
3. From the gastrosplenic trunk;
4. From the gastrohepatic trunk.
• Division
It completes an arch before joining and running along the lesser curvature 2 fingerbreadths below the cardia. It then divides into anterior (a) and posterior (b) branches that run down along the lesser curvature to join the terminal branches of the right gastric artery.
• Other branches
The left gastric artery gives off several branches:
1. Accessory left hepatic artery; there is frequently an accessory left hepatic artery, which is of no clinical significance,
2. Anterior and posterior cardioesophageal arteries (supplying the cardia and abdominal esophagus).
• Right gastric artery
• Normal
The right gastric artery usually originates from the common hepatic artery.
• Variations
In some patients, it originates directly from the:
1. Gastroduodenal artery;
2. Left hepatic artery, or;
3. Proper hepatic artery.
• Vascular arch
The right gastric artery joins the stomach at the level of the pylorus. It then divides into anterior and posterior gastric branches that run along the lesser curvature to join the left gastric artery network at the level of the incissura, junction between the horizontal and vertical regions of the stomach.
The right and left gastric arteries compose the vascular arch of the lesser curvature.
5. Greater curvature
• Definition
The greater curvature of the stomach is bordered by the greater omentum and gastrosplenic ligament. The peritoneal covering of each of these 2 structures is in direct contact with the gastric visceral peritoneum. The greater omentum spreads over the transverse colon and extends beyond it inferiorly at the level of the body and horizontal region of the stomach. At the level of the fundus, the greater omentum becomes the gastrosplenic ligament. The right and left gastroomental arteries and the short gastric vessels form the vascular arch that runs through the anterior layer of the greater omentum.
• Right gastroomental artery
1. The right gastroomental artery originates from the division of the gastroduodenal artery at the inferior aspect of the duodenum.
2. It runs along the greater curvature of the stomach from right to left at an average distance of 1 cm.
3. The branches originating from the right gastroomental artery supply the anterior and posterior aspects of the stomach and the omentum.
• Left gastroomental artery
The left gastroomental artery originates from the splenic artery. It supplies the middle portion of the greater curvature and runs through the gastrocolic ligament to join the terminal branches of the right gastroomental artery.
The right and left gastroomental arteries thus form the vascular arch of the greater curvature.
• Short gastric vessels
The short gastric vessels originate from the terminal branches of the splenic artery.
Alternatively, they originate either directly from the trunk of the splenic artery or from its terminal branches.
They are composed generally of 2 to 6 vessels that run from the splenic hilum to the stomach via the gastrosplenic omentum.
The largest vessel (the posterior gastric artery) joins the posterior aspect of the stomach and divides to supply the fundus and the cardia.
• Avascular window
An avascular window of only 2 peritoneal layers is situated between the last short gastric vessel and the origin of the left gastroomental artery. The 2 layers of peritoneum split to form the omental bursa opposite the splenic artery.
6. Indications 1
Modified gastrectomies can be performed for benign and malignant tumors, superficial lesions, and sarcomas. Intraoperative gastroscopy assists the surgeon in localizing and removing small tumors that may not be readily visible on laparoscopic examination.
7. Indications 2
Main operative indications for video-assisted gastrectomies:
8. Operating room set up
• Patient
- general anesthesia;
- nasogastric tube;
- supine position;
- arms at a right angle and legs apart (arms alongside the body for certain authors);
- reverse Trendelenburg position with a 10° or 30° tilt;
- dual-lumen gastric tube (used to totally empty the stomach);
- urinary catheter (used in case of prolonged procedure, optional);
- antibiotic prophylaxis.
• Team
There must be ample space for the anesthetic equipment, as well as a perfectly adapted operating table. For optimal safety conditions and comfort, the operating room should be ergonomic.
1. The surgeon stands between the patient’s legs.
2. The first assistant stands on the patient’s left.
3. The second assistant stands on the patient’s right.
4. The scrub nurse stands on the surgeon’s right.
• Equipment
1. Laparoscopic unit (3-chip camera if possible, light source, insufflator)
2. Two additional high-quality monitors
3. Anesthetic unit
4. Arm holders
9. Instruments
• Positioning
A: 0° laparoscope
B C: Atraumatic grasper, monopolar and bipolar diathermy scissors, suction-irrigation device
D: Dissecting hook, monopolar and bipolar diathermy scissors, linear stapler, suction-irrigation device, needle holder
E: Liver retractor
F: Grasper
• Optical
A: Most procedures are performed using a 0° laparoscope, but a 30° laparoscope can be useful when visualization is poor.
• Operating
D: Dissecting hook, monopolar and bipolar diathermy scissors, linear stapler, suction-irrigation device, needle holder
F: Grasper
• Retractors
B C: Atraumatic grasper, monopolar and bipolar diathermy scissors, suction-irrigation device
E: We prefer to use an atraumatic liver retractor, however, a fan-like liver retractor can be used.
10. Trocar placement
• Landmarks
1. Xiphoid process
2. Costal margin
3. Linea alba
4. Midclavicular lines (mamillary lines)
5. Anterior axillary lines
5 or 7 trocars are used in the procedure. Most authors use 10/12 mm trocars exclusively in order to be able to apply clips or to introduce a linear stapler at all trocar sites.
Trocars must always be placed in such a way as to avoid contact between instruments.
• Pneumoperitoneum/ exposure
The pneumoperitoneum is preferably obtained by introducing the first trocar under direct visual control. This trocar is placed in the umbilicus.
The peritoneal cavity is insufflated with carbon dioxide at a pressure of 12 mm Hg.
The exposure is aided by the 10° to 30° tilt of the operating table (the patient’s head higher than the feet).
• Trocars
The remaining trocars are introduced under visual control.
The first trocar (A) is introduced in the umbilicus. Two trocars are positioned below the right costal margin (B) and the left costal margin (C) on the midclavicular line. A fourth trocar (D) and a fifth trocar (F) are positioned on the midclavicular line at umbilicus level. A sixth trocar (E) is introduced at the level of the xiphoid process.
• Size and position
Trocar A (10/12mm) situated subumbilically accommodates the laparoscope.
Trocar B (10/12mm) situated on the right midclavicular line, just below the costal margin, accommodates the grasper.
Trocar C (10/12mm) situated on the left midclavicular line, just below the costal margin, accommodates the grasper.
Trocar D (10/12mm) situated on the left midclavicular line below the umbilicus, accommodates dissecting instruments and suture.
Trocar E (10/12mm) situated at the level of the xiphoid process, accommodates the liver retractor.
Trocar F (10/12mm) situated on the right midclavicular line below the umbilicus accommodates an atraumatic grasper.
11. Tumors/anterior aspect
Tumors situated at the anterior aspect of the stomach or those that are easily identified as they protrude into the abdominal cavity are resected using a linear stapler.
Four trocars are required. The umbilical trocar accommodates the laparoscope. To expose the area of resection, graspers are introduced via 3 trocars:
- right and left subcostal,
- epigastric.
Linear stapler cartridges are successively applied to resect the tumor.
12. Tumors/posterior aspect
• Dissection
The dissection of the posterior aspect of the stomach requires division of the greater omentum and opening of the lesser sac. This is generally followed by retraction of the stomach to provide exposure. This procedure may not give ideal access to lesions in difficult locations, leading several surgical teams to propose a more rapid technique to perform the resection of lesions that are posterior or situated higher.
• Anterior gastrotomy
An anterior gastrotomy is performed first to identify the lesion. Two graspers are used to expose the posterior gastric wall around the lesion, avoiding direct contact with the tumor to minimize the risk of rupture. The tumor and a part of the posterior gastric wall can be externalized via the anterior gastrotomy. A stapler is fired successively, completely resecting the tumor. The anterior gastrotomy is closed using either a simple continuous suture or another firing of the linear stapler.
13. Tumors/hard to identify
• First and second steps
Small, hemorrhagic lesions, as well as some superficial cancers can be resected provided they are perfectly localized via gastroscopy.
- First step: creation of the pneumoperitoneum,
- Second step: clamping of proximal jejunum to avoid intraluminal distension (or placement of a balloon-tipped catheter in the duodenal bulb).
• Third step
The gastric wall is transilluminated.
• Fourth step
The neoplastic zone is grasped with a Babcock forceps by the surgeon.
• Fifth step
The gastric neoplastic zone is resected. Gastroscopy checks for a complete resection and the existence of sufficient safety margins in case of a potentially malignant tumor. These margins will be, in any case, confirmed by frozen sections.
14. Complications
It is generally accepted that the intraoperative risks for laparoscopic and open gastric resection are comparable. On the other hand, comparative studies published in the literature report a lower incidence of postoperative complications following the laparoscopic approach (ileus). Postoperative recovery and quality of life appear to be equivalent if not superior to the open results (Kitano et al., 2002a, 2002b; Mochiki et al., 2002; Uyama et al., 1999).

Theoretically, the laparoscopic approach to gastric surgery should offer the same advantages of any laparoscopic approach, namely a faster recovery, reduced postoperative pain, and a lowered incidence of pulmonary complications.
15. Intraoperative complications
1. Intraoperative hemorrhage can occur due to several factors:
- loosening of a surgical knot or suture: this can be controlled by direct compression and resuturing;
- minor oozing: usually easily controlled by monopolar or bipolar coagulation;
- venous injuries: difficult to control, may require en masse suturing of the tissues;
- hepatic or splenic injuries with parenchymal hemorrhage: these can be controlled using direct compression, Argon Beam coagulation, fibrin glue or collagen based hemostatic aid application, splenectomy if indicated (the ligature of the splenic vessels deprives the stomach of some of its collateral blood supply and may mandate a completion total gastrectomy in some situations);
- bleeding from the staple lines: this can be controlled with a hemostatic suture application;
- biliary and pancreatic injuries can cause bleeding. A gallbladder injury or inadvertent ligature of the cystic artery frequently requires cholecystectomy. An injury to the common bile duct or main pancreatic duct requires drainage or a primary protected repair; while a small lateral injury to the CBD can be repaired primarily, a more complex biliary injury or complete division of the CBD requires either primary end-to-end repair over a T-tube or a Roux-en-Y choledocho- or hepatico-jejunostomy.

2. Gastric ischemia in the course of a subtotal gastrectomy, secondary to simultaneous ligature of the left and right gastric arterial trunks as well as the short gastric vessels (or an emergent splenectomy for control of hemorrhage) mandates conversion to a total gastrectomy.
Ischemia of the transverse colon secondary to sacrifice of the middle colic artery in an elderly patient with poor collateral blood supply requires a segmental colectomy of the ischemic segment.
Ischemia of the Roux limb is handled by resection of the ischemic segment and reconstruction of a new Roux limb.
16. Postoperative complications
Early postoperative complications are defined as those complications occurring within 30 to 60 days of surgery, depending on the author. They are observed in 10% to 30% of patients (Bozzetti et al., 1997; Hayes et al., 1999). These complications are generally significant and often result in prolonged hospitalizations, added costs, and an elevated mortality rate. The most common complications include postoperative hemorrhage, fistulas, and abscesses (Bozzetti et al., 1997). Of 121 total gastrectomies with lymphadenectomy, 9% had anastomotic leak, 0.15% duodenal stump leak, and 10% other fistulas (Hayes et al., 1999). The management of these complications has evolved rapidly due to our improved understanding of the pathophysiology of such injuries, improved imaging as well as interventional radiological abilities and an understanding of the high morbidity associated with surgical re-explorations. While most such complications can be treated conservatively, reoperative surgery remains of value in rapidly addressing some acute complications. Other postoperative complications seen following laparoscopic gastric surgery include acute pancreatitis, motility disorders, and lymphorrhea.

1. Intraperitoneal hemorrhage can occur secondary to a delayed loosening of a vascular suture, or a delayed rupture of a subcapsular splenic hematoma. This usually mandates a rapid re-exploration of the patient to identify and correct the etiology of the bleeding (re-suturing, splenectomy) and evacuate the hematoma.

2. Gastro-intestinal hemorrhages following gastrectomies are reported in 1% to 2.5% of cases (Bozzetti et al., 1992; Kyser et al., 1997). They are most commonly due to a recurrent ulcer or suture line bleeding. The management of recurrent ulcer bleeding may require reoperative surgery, medical therapy of Helicobacter pylori, endoscopic measures for hemorrhage control (local injections of epinephrine or fibrin/cyanoacrylate glue) or selective embolization of the gastroduodenal artery. Suture line bleeding is generally managed conservatively, initially with nasogastric suction and appropriate resuscitation. If the above management fails then reoperation may be indicated to oversee the bleeding site via a vertical gastrotomy.

3. An enteric fistula is defined as leakage of intestinal contents outside of the gastro-intestinal tract. This includes leakage of intestinal contents, bile or pancreatic juice. The severity and morbidity of such leaks is determined by the patient’s clinical course. A small, contained leak often remains asymptomatic or leads to a delayed anastomotic stricture. It may lead to a local inflammatory reaction with localized peritonitis with an entero-cutaneous or entero-enteral fistula. The reported rate of anastomotic leaks following gastric surgery is 4% for esophageal anastomoses (Fahn et al., 1997) and 2.7% for gastric suture lines. A major anastomotic disruption occurring early in the postoperative course leads to generalized peritonitis, with a mortality rate of 50%.

4. Postoperative abscesses are diagnosed clinically (fever and abdominal pain in the postoperative setting) coupled with imaging (CT scanning). These can often be managed with percutaneous image guided aspiration and drainage.
17. Functional complications
1. Motility disorders
Early postoperative vomiting may occur secondary to anastomotic edema. It is often self-limiting and is usually managed via continued nasogastric aspiration.

2. Surgically induced motility disorders
Anastomotic strictures are rare, occurring in less than 1% of cases (Johannson et al., 2000), and are almost never reported when the diameter of the stapled anastomosis is greater than 28 mm. Such strictures manifest themselves within the first 3 postoperative months and may resolve spontaneously or following endoscopic dilatation in the majority of cases.

3. Motility disorders following Billroth II gastro-jejunostomy
a. Afferent limb obstruction
The afferent limb is composed of the remaining duodenum as well as proximal jejunum. Afferent limb obstruction can occur if the limb is too short and stretched out over the colon or too long, leading to intermittent volvulus. A surgical bypass of the obstructed limb proximal to the site of obstruction or fixation of the afferent limb in case it is too floppy may be indicated.

b. The afferent loop syndrome is caused by a partial high-grade obstruction of the afferent limb leading to duodenal distention associated with abdominal pain and relieved by copious projectile bilious vomiting. The afferent limb obstruction can occur secondary to acute angulation of a short limb, afferent limb torsion, adhesions, mesocolic window stricture, anastomotic stricture or invagination of the afferent limb into the anastomosis. Treatment of this condition is difficult and often requires remedial surgery.

c. The blind loop syndrome occurs secondary to bacterial overgrowth in a partially obstructed afferent limb. This limb empties occasionally in a sudden and massive fashion, dumping its septic contents in the gastrointestinal tract, leading to diarrhea. The treatment of this entity may require re-establishment of intestinal continuity to the duodenum by conversion of a gastro-jejunostomy to a gastro-duodenostomy.

d. Afferent limb internal hernia occurs most commonly secondary to incarceration of a small bowel loop into the mesocolic window. This may also be accompanied by herniation of the anastomosis into the lesser sac. Treatment is surgical with reduction of the internal hernia.

e. Gastric outlet obstruction can occur secondary to anastomotic stricturing or to invagination of the jejunal limb into the anastomosis. Revision of the anastomosis is often necessary.

4. Motility disorders following Billroth I reconstruction
a. Acute gastric dilatation is usually treated by naso-gastric suction coupled with parenteral nutritional support or a decompressive gastrostomy.

b. Acute peptic esophagitis can be mechanical in nature due to a pre-existing hiatal hernia, indwelling naso-gastric tube or stretching of the angle of His. It may also be secondary to bilious reflux following proximal gastrectomy encompassing the cardia or due to damage to the lower esophageal sphincter sustained in the course of an antrectomy-vagotomy. However, it can often be successfully managed medically; operative hiatal repair or duodenal diversion may be indicated.

5. Other functional complications
The \'dumping syndrome\': it manifests in 2% to 88% of cases according to the chosen definition (Behrns and Sarr, 1994). It occurs in 2 forms, early or delayed:
- early dumping (within 5 minutes to an hour)
- delayed dumping (within 2-3 hours of meals, relieved by food intake): this is due to rapid absorption of carbohydrates in the afferent limb with reactive hyperinsulinemia leading to secondary hypoglycemia.
Diarrhea: a non-specific complication observed in 5% to 20% of cases.
Anastomotic stricture: the small gastric stump syndrome is due to a combination of gastric atony and acute reduction in gastric volume. It resolves spontaneously.
A bezoar requires endoscopy and re-exploration.
Ulcer-type pair or postprandial heartburn can be observed.
18. Conclusion
Laparoscopic partial gastrectomies have been rendered possible by the development of automatic linear staplers. With the availability of a wide range of instruments, the surgeon can apply the laparoscopic approach for a multitude of indications (30, 45 or 60 mm fixed and curved staplers with variable thickness allowing for treatment of all types of 1, 1.5 and 2 mm tissues).
Paradoxically, the required expertise for the application of sutures, though fundamental in conventional surgery, is not required in this case.

The advantage of the laparoscopic approach to gastrectomies lies in the fact that it makes possible a complete abdominal exploration and, for well-trained surgical teams, a dissection comparable to that performed in open surgery.
Early findings in the literature do not report complications specifically related to this approach. While the operative time may be considerably longer, the patient’s postoperative comfort is improved. Recovery of bowel function, the amount of food ingested, the performance index and the patient’s satisfaction are better after a video-assisted procedure than after a conventional procedure.
Performing anastomoses entirely via endoscopy does not seem to offer obvious advantages, however. More often than not, the incision required to extract the specimen makes it possible to perform anastomoses easily.
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